Not enough doctors? Nurses fill the gap after earning online degrees

Simmons College faculty watch a live-streamed address by class speaker Tara Zamarron from Washington state during a graduation ceremony for an online master's degree program for training nurse practitioners. Josh Reynolds for STAT

Pulse of Longwood takes you inside one of the nation’s largest hubs of hospitals and biomedical research.

Way out in rural Washington state, nurse Tara Zamarron stood in a friend’s living room and donned a cap and gown she had received in the mail. She flipped on a video camera and appeared on screen 3,000 miles away. In a disjointed but jubilant virtual graduation ceremony, she joined the latest batch of nurses setting off to treat their own patients by earning online master’s degrees.

“Yay everyone!!!!” she typed on the screen.

Zamarron, who’s 39, was one of 20 nurses honored last week during the second-ever graduation ceremony for an online master’s degree program at Simmons College. The degree gives nurses the advanced clinical training and coursework they need to become nurse practitioners in family medicine.

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In launching the program in 2013, Simmons, a private university in Boston’s Longwood Medical Area, joined a national surge: 17 new online nurse practitioner programs opened between 2009 and 2014, according to the American Association of Colleges of Nursing. While students do all their coursework online, they do still train in practical skills with patients in clinics and hospitals.

After snagging her new degree, passing a national certification exam, and earning a state license, Zamarron will be able to prescribe medicine and diagnose and treat patients without a physician’s supervision. She’ll do that in a corner of southeast Washington that has a crying need for more primary care providers for its 9,000 residents.

Zamarron, who has been a nurse for 19 years, lives “in the middle of the desert,” two hours from the nearest major city.

Her story illustrates just what Judy Beal, dean of Simmons’ nursing school, said she was aiming for with the new Nursing@Simmons program: to open the doors to far-flung nurses who can alleviate a national shortage in primary care providers. As more patients seek medical care due to the Affordable Care Act, as the population ages and grows, and as older physicians retire, the nation could face a shortfall of 31,000 primary care physicians by 2025, the Association of American Medical Colleges has warned.

Many hospitals, community health clinics, and state policymakers are turning to nurse practitioners to fill that gap. Nurse practitioners have equivalent, or sometimes better, patient outcomes compared to doctors, according to a review of studies from 1990 to 2008. But, contrary to recommendations by the Institute of Medicine, the American Medical Association and other physician groups have fought to restrict nurse practitioners’ autonomy, arguing they don’t have the proper training to prescribe medicine and treat patients on their own.

Many newly minted nurse practitioners will face limitations on the job. The majority of states, including Massachusetts, restrict them from practicing to the full scope of their training, requiring outside supervision from, or a collaborative agreement with, a doctor.

But that’s changing: Since 2010, eight more states have passed laws allowing nurse practitioners to work without a doctor’s supervision, bringing the total to 21 states.

State policies aren’t stopping students from pouring through the virtual doors of online programs. So far, 1,472 students have enrolled in Nursing@Simmons from 43 states, plus Puerto Rico, the US Virgin Islands, Israel, and US military bases abroad. Enrollment is quickly surpassing that of Simmons’s on-the-ground master’s program, which has been around since 1978.

“I keep on thinking, how much is too much?” Beal said. “Do we have enough resources? When is the growth going to stop?”

Nationally, over 42,000 students were enrolled in online master’s in nursing programs in the 2014-15 academic year, according to U.S. News & World Report, which started ranking online nursing master’s degrees in 2013.

Simmons’s is now one of 147 such programs that are ranked by U.S. News, up from 96 in 2013. To be ranked, the programs must be accredited by one of the two nursing school accreditation bodies, and must choose to answer a U.S. News survey, so the rankings don’t reflect the total number of programs nationwide.

Comparisons of student completion rates or national certification exam pass rates of online versus traditional programs are hard to come by. Beal said even she can’t compare certification rates of her own online and on-the-ground students, because the scores reported back to her are anonymized.

Facing budgetary woes, Simmons last year made the painful decision to close its brick-and-mortar, all-women MBA program after 40 years and move it online. Beal acknowledged that the rationale behind opening up online nursing classes is partly financial, too.

“This is a business decision on the part of the college, clearly,” Beal said. “But from my point of view, it’s really one that’s working to increase the numbers of nurse practitioners in primary care across the country.”

The biggest challenge of Nursing@Simmons is to make faculty and students feel connected to the college, Beal said. Simmons does that by bringing students to campus before they start clinical rotations, and also by offering a virtual “classroom” experience, where students have to show up at an appointed time and appear via webcam along with their classmates.

“In some ways it’s better than on-the-ground,” Beal said. Classes are small, with no more than 15 students. And unlike in big lecture halls, the professor “knows if they are sleeping in class. There is no back row that a student can hide in and surf the internet.”

To thwart cheating, students take tests at the same time, with webcams watching to see if their eyes divert from the screen, or if they leave the room.

Beal said it can also be challenging to find preceptors — physicians or nurse practitioners who volunteer to train students for clinical rotations — for all of the far-flung students, though it’s easier than in Massachusetts, where there’s tough competition from other nursing schools.

Simmons College faculty and staff watch live streams of graduates from a new online nursing program.

Last week, Beal donned a red robe and spoke from a podium in a Simmons classroom, congratulating new graduates of online nursing and social work programs — none of whom were actually in the room. Instead of handing out diplomas, staff mailed them out, then asked the graduates to flip on their cameras when their names were called. Due to technical difficulties, not all of the graduates made it onto the screen. Those that did revealed joyous scenes in living rooms and kitchens, with kids and parents popping into the frame.

One of the graduates, Angela Vera Jackson, 42, sat in a back room in a medical clinic she runs in Porterville, Calif., near the Sequoia National Forest. Behind her stood a doctor, three employees, and two patients. When her name was called, the room broke into applause, which rippled down the hall in the waiting room, she said.

Jackson, who’s from Puerto Rico, will fill a much-needed role — a primary care provider who speaks Spanish. She said patients at the clinic, who got word of her upcoming graduation, have already started getting in line to become her patients.

Jackson said the online setup was crucial because the nearest nursing graduate school is an hour-and-a-half drive away. Now she’s already setting her sights on a doctoral degree, which she also plans to complete online.